“We were kind of reading the tea leaves for some time and felt that local leadership believed what Vanguard was offering was their best option,” Carrier said. “So we've been trying to prepare ourselves for some time in case it did go that way.”

Both Christus and the health science center are promising an orderly transition for the sake of the children, as in any divorce. But Carrier's promise also contains the hint of potential litigation.

He feels the health science center, as it negotiated with other potential partners, was in violation of their affiliation agreement. That agreement extends to 2024 but can be canceled by either party with three years' notice.

“Quite frankly, we felt there's been a breach in the affiliation agreement for some time,” said Carrier, who declined to be specific about what terms had been violated. “We've given them notice to that. Our hopes are that we don't come to any sort of legal dispute over it. But we are committed to working out an orderly transition plan, to make sure that the patients are well-served and don't go without receiving needed care.”

Santa Rosa's Plan B

In April, Christus announced it was launching an aggressive, $135 million plan to close adult services downtown and rebuild the entire campus as Children's Hospital of San Antonio — promising a bigger, state-of-the-art academic facility in about two years. That plan is under way.

Dr. Francisco González-Scarano, medical dean of the health science center, also believes a careful, well-orchestrated transition will be in everyone's best interest — including Christus. Health science center pediatricians and subspecialists make up about half the medical staff, and replacing them won't be easy.

“Christus can't suddenly hire 100 physicians,” González-Scarano said. “There isn't a bus out there where you put them and bring them down. They know that. There aren't enough pediatricians in San Antonio that are wandering around looking for a hospital to park themselves in.

“On the contrary, we need more pediatricians in the city and the region. So we believe it is in all of our best interests to have an orderly transition of faculty and patients.”

Recently, Christus began talks with Texas Children's Hospital in Houston — ranked fourth-best in the nation by U.S. News and World Report — about a new partnership agreement that would help Christus find new subspecialists and medical residents if the health science center walked away.

But Carrier said he deliberately avoided formal talks with Baylor College of Medicine, the academic partner of Texas Children's, in keeping with their interpretation of the affiliation agreement with the health science center until Friday, when the choice of Vanguard and CHOP was made.

González-Scarano acknowledges that Christus might not have to look far for at least some of those 100 doctors. A few faculty members, loyal to the nonprofit mission of Christus — rather than the for-profit hospital Vanguard and CHOP plan to build — may elect to stay.

“There's always going to be people who are comfortable with the current situation,” González-Scarano said. “The majority of (faculty) prefer the change, is my understanding. They do so, yes, with some trepidation. After all, it's a change.”

While the medical school wanted to build the new children's hospital near its main campus, as opposed to the downtown site Christus was rebuilding, location wasn't the only issue, González-Scarano said. The idea of designing an entirely new, state-of-the-art hospital from scratch was appealing.

'A different world'

It was a bitter controversy over location that killed a plan 20 years ago to build a new, academic children's hospital in the South Texas Medical Center. Politicians and some downtown doctors fought to keep the new hospital downtown, where poor families would have easier access.

Former Mayor Henry Cisneros, whose son John Paul underwent life-saving heart surgery at CHOP in 1993, said location no longer should be an issue.

“This is a different world now,” Cisneros said, adding the plan also includes outpatient facilities to be located downtown and throughout the region. “People can get around more easily. And the right place to put the major research facility is in the medical center, with the support system it needs.”

But Carrier said he believes the loyalty earned by the Catholic-owned system will give it an advantage over whatever CHOP and Vanguard build across town.

“We will be the only not-for-profit children's hospital in San Antonio,” Carrier said. “Children's hospitals traditionally require significant amounts of philanthropy to succeed. Because contrary to what many people believe, it's not a profitable business because of the cost of caring for these kids. We rely a lot on philanthropy. And my personal opinion is, I don't give to for-profit institutions.”